The stagnant allocations in the Budget for health, education and nutrition reminded me of the film The Last Czars. Emperor Nicholas asks his communist captors why he has been imprisoned despite loving Russia and being loyal to it. The captor replies, “You loved Russia, but not the people.” In today’s world of governance, are Budgets a reasonable way of assessing this quality in our leaders for those who elected them?
Budgets are boring documents if we look at them only in terms of financial allocations to sectors. Yet, they are eagerly awaited because they validate the true intent and vision of the government — who or what it “loves” more. And such a judgment is based on the extent to which the Budget helps in furthering the equitable access of all citizens to basic public goods.
Soon after World War II left the U.K. devastated, the National Health Service was launched as a means to revive society. Envisioning a welfare state, the social economist William Beveridge sought to address the “five giant evils: want, disease, ignorance, squalor and idleness.” If India’s vision is driven by such an articulation, then investments need to be prioritised first towards basic services such as nutrition, health, employment, education, environmental sanitation and hygiene, rather than airports, highways and speed trains.
It may be argued that the government has been fair in this year’s Budget by providing free foodgrains to 80 crore poor people; developing 500 backward blocks; broadening access to housing, clean water, and toilets; providing employment through the rural employment guarantee scheme; and providing opportunities for skill development. But these can only have partial gains; they do not necessarily address the issue of widening inequality. Besides, for sustainable, long-term growth of the country, expanding universal access to high quality education, healthcare and nutrition (not just foodgrains but proteins and other supplementary foods that are currently unaffordable) is imperative. No country can go far if a significant proportion of its population is illiterate, unhealthy or malnourished. All the countries that are developed today invested well in education, health and nutrition. Studies in the U.S. show that after the Reagan era, innovation and scientific capability took a hit when public investment in education was reduced to push privatisation. Even Nicaragua, despite its economy being in shambles, invested in health and education. The tragedy is the failure of our political leadership, since Independence, in understanding the centrality of universal education and health to growth.
In view of the above, the Budget is disappointing. A study showed that 230 million Indians slid into poverty due to COVID-19. The ASER report shows the abysmal state of education — many Class 5 students are unable to read a Class 2 textbook. NFHS-5 data show that among children aged below five years, 35.5% were stunted and 32.1% were underweight. Yet, the allocations for education and nutrition are stagnant. The budget for midday meals reduced by 9%, not counting for inflation, even as data show a shift in enrolment from private to public schools with private schooling becoming unaffordable. Disease burden is rising with non-communicable diseases, mental health and geriatric care adding to the load of communicable diseases. India lacks adequate human resources, infrastructure and access to affordable diagnosis and treatment.
COVID-19 sharply brought into focus three major fault lines: the lack of financial risk protection, which is why citizens incurred huge expenses, estimated to be more than ₹70,000 crore, even as their incomes fell; a broken down primary health system, particularly in the north, that resulted in a large number of avoidable deaths; and the absence of well-equipped and functioning district hospitals to cope with demand. India needs an infusion of resources and a bold imagination to address these.
Besides, it also showed us the chaotic state of the regulatory framework. Many laws have serious infirmities and embed conflicts of interest. Some need to be scrapped and some amended, for without sound governance, opening up health to market forces can be disruptive and hurt patients, particularly the poor. COVID-19 also underscored the need to invest in public health to build our disease surveillance system and strengthen resilience to such shocks.
Addressing all this is urgent because there is no guarantee that the worst is over. It is the responsibility of a government to firewall its citizens against any such eventuality by improving the healthcare system and reducing vulnerability. We need political leadership backed by adequate funding in order to rebuild our public health system, promote scientific research, and expand health security. Constructing 157 nursing schools and trying the impossible of “eliminating” a genetic disease is no answer to these serious structural problems.
Equity and justice are values that must guide a polity to build a nation. Measuring policy and money allocation only in terms of political expediency is short-term and unsustainable. When such structures collapse, as they will, it is the poor and marginalised who will suffer disproportionately. But then disease is an equaliser — many rich people also died during COVID-19 for want of access to a hospital bed or oxygen. The price we paid then, and the lessons learned, need to be remembered. Neglecting the health sector and denying it of critical investments has consequences.